Provider Demographics
NPI:1679670004
Name:INNATE CHIROPRACTIC GROUP, INC.
Entity Type:Organization
Organization Name:INNATE CHIROPRACTIC GROUP, INC.
Other - Org Name:ROCKINGHAM CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MGR.
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:FULP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-623-6100
Mailing Address - Street 1:1009 S. VAN BUREN ROAD
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5343
Mailing Address - Country:US
Mailing Address - Phone:336-623-6100
Mailing Address - Fax:336-623-5100
Practice Address - Street 1:1009 S VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5343
Practice Address - Country:US
Practice Address - Phone:336-623-6100
Practice Address - Fax:336-623-5100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2499111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0831MOtherBCBS
NCU69435Medicare UPIN
NC2454221Medicare ID - Type Unspecified